In Africa, hope emerges

Senegal's aggressive AIDS strategy saves thousands from infection

By John Donnelly, Globe Staff | August 13, 2003

DAKAR, Senegal --
One held a baby doll whose startling blue eyes stared into the darkness. Neither woman stirred, not after a night of carousing, dancing, and enduring the rough grasps of men. This was a moment of precious peace.

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Day broke, and amid barking dogs and crying babies in their concrete apartment block, the two women, both prostitutes, lingered on their bed. They were irritable. To eat, they needed to work, to "go out into the night," as they put it.

"This is a violent life," Anthonia Jacob, 28, said in her husky voice, still clutching her doll. "One thing, though -- I'm very careful. I make sure they always use condoms. That's why I'm healthy."

On a continent where a breathtakingly high percentage of prostitutes carry and spread the AIDS virus, Jacob and her roommate, Kate Eno, are HIV-free.

Senegal deserves some credit.

This impoverished nation of 10 million people on Africa's west coast has shown how AIDS can be held at bay in places where the disease is a persistent, voracious killer. In 12 other African countries, more than 10 percent of people ages 15 to 49 are infected with HIV, the virus that causes AIDS. In Senegal, the infection rate has never risen above 2 percent; its prevention efforts have saved tens of thousands of lives.

Senegal's largely unheralded efforts stand in bright contrast to the unfolding global tragedy, vast and nearly invisible to the developed world, of needless deaths: Around the world, an estimated 8 million people die every year -- about 22,000 a day -- because they do not have access to basic health care, according to a World Health Organization commission on health and economics. AIDS alone kills 3 million a year.

In a series of articles this year, the Globe is examining why these people died, and how successes in some countries, such as Senegal, have belied a common view that the crisis in poor countries is beyond remedy.

The power of Senegal's example in fighting AIDS over 18 years can be seen in the good health of prostitutes such as Jacob and Eno. It can also be noted among fishermen who might easily become disease carriers, but who generally have not. The example is also set by the nation's health care leaders and scientists.

Senegal's strategy relies on several elements. An agreement between government officials and Islamic leaders has allowed more open discussion about sexual behavior that can lead to HIV infection. A home-grown team of scientists is credited with research breakthroughs that have sparked national pride. And health programs aimed at people on the margin of Senegalese society have reached those most likely to spread the disease.

None of this has been easy, although Senegal has some advantages of geography and culture.

Senegal is 95 percent Muslim; core values are clear. Fathers and mothers preach against premarital sex. Muslim boys are nearly uniformly circumcised, which studies suggest can help reduce HIV infections. And Senegal is bordered by the Atlantic Ocean to the west, and by five countries -- Mauritania, Mali, Guinea, Guinea-Bissau, and the Gambia -- that have relatively low HIV rates.

Population movements among neighboring nations are not a major cause of the virus's spread. This is in contrast to the cluster of southern African nations where AIDS is migratory -- and rampant.

Senegal's leaders have also played constructive roles, a rarity in Africa until recently. "We started early," said Awa Marie Coll-Seck, the health minister. "Our government never asked us to hide the figures. At the same time, we had some friends working in other countries who were almost going to jail because they said, `I have a case in my clinic."'

Health workers and police have stepped up their regulation of prostitutes. Since 1969, Senegal has allowed prostitutes older than 21 to work their dangerous trade as long as they register with a health clinic and see doctors for a monthly checkup and for free condoms.

It is a program unique in Africa. Senegal even extends health and dental benefits to the children of prostitutes who comply with the registry. The government also began meeting quietly, more than a decade ago, with the nation's Islamic leaders, who began to preach that the threat of disease was another strong reason for abstinence and marital fidelity.

The religious leaders also tacitly agreed not to object as the government promoted the use of condoms. The government further tightened screening of blood donations, and intensified efforts to treat other sexually transmitted infections, which are known to increase the risk of contracting HIV.

And Senegal did something else that hasn't been matched elsewhere in Africa: It developed a corps of scientists to work alongside senior political leaders and foreign disease specialists to battle AIDS. Since 1985, Senegal's scientists have been monitoring HIV and other sexually transmitted diseases in prostitutes. They have also developed new and less-expensive methods for HIV studies and have laid down guidelines for treatment.

There were four Senegalese specialists in 1985; there are 60 now. The effort is aided by a longtime partnership with the Harvard School of Public Health, which has sent scientists to Senegal, has trained Senegalese scientists at Harvard, and has hosted AIDS conferences in Dakar. Assistance also has come from the European Union, France, and several US sources, including the Agency for International Development, the National Institutes of Health, and the Defense Department.

Senegal has not received more foreign assistance than other African countries. What it has done is leverage overseas efforts with millions of its own money. The consensus among outside observers is that the money, foreign and domestic, has been wisely spent.

The results have been striking. In the late 1990s, when Senegalese troops returned from a peacekeeping mission in Rwanda, none of the soldiers tested positive for HIV, while forces from Belgium returned with 3 percent infection rates.

The Senegalese still worry about gaps in their AIDS-fighting strategy. Rural areas receive too little attention. HIV-infected people are almost always afraid to tell others of their plight, and the majority of those infected remain outside the health care system.

Poverty has pushed more young women into prostitution, and those under age 21 are not eligible for free health care. Many health workers, exhausted by the long fight, wonder how long they can sustain the effort.

"What I tell everyone is not that we are happy, but that we need to continue our work, we need more financial support," Coll-Seck said.

"We have weaknesses. We have to always remember that AIDS is the result of a short-term act, but it is a long-term work."

The fishermen's tale

Dakar, a city of 2 million people, runs along the Atlantic shore. It has replaced the Ivory Coast capital of Abidjan as the commercial and cultural hub of West Africa.

Senegal's capital is a city oriented toward the ocean, where legions of fishermen arrive in late afternoon with buckets of grouper and red snapper in their wooden boats, and thousands of people exercise at dawn and dusk. Some beaches are littered with chopped-off fish heads; others resemble fitness centers, teaming with hard-bodies, like a slice of Southern California incongruously grafted onto Africa.

Both the fishermen and the runners reveal something about AIDS here.

In the eyes of the health researchers and scientists, the fishermen represent a potential threat to Senegal's efforts to control the spread of AIDS. Many travel to faraway ports and spend their cash on prostitutes in areas with much higher rates of HIV infection.

In the past few months, researchers have started a pilot program that tests "bridge groups" -- fishermen, migrant workers, soldiers, and others who can spread the virus by bringing HIV back into the country -- for HIV and other sexually transmitted diseases.

One night this summer, Papa Demba Sene, 33, pulled his boat onto the shore of the Soumbe Dioune beach, helped by a dozen young men, who were paid in fish. Sene, a father of two, was returning from an overnight trip. Asked about AIDS, he said he knew about the dangers, but he still visits prostitutes on some trips.

"Just last night, I was with a prostitute," he said loudly as the men around him laughed. "And you know what happened? My condom broke! The thing broke!"

"What did you do?" someone asked.

"I stopped, of course," he said in an even louder voice. "It's too dangerous not to use a condom. You have to use two condoms, don't you?"

Most of the fishermen of Senegal are traditional men who do not seek out prostitutes, many among them said. They are people like Ousmane Badju, 41, father of three girls ages 14, 8, and 4.

"We warn our daughters about AIDS," Badju said one morning recently, sitting on a bench on a street a block from the ocean as men around him repaired their huge nets. "We say to our daughters, `The only way to avoid the virus is never to have sex before marriage,"' he said.

His eldest daughter, Odette, does not go out with friends at night, he said. "I would never accept that. She doesn't have the maturity, she cannot fend for herself at age 14. And she would not dare to ask."

A handful of men around him nodded their heads in agreement. "It is a good thing to live in a community like this," Badju said. "We know each other. We watch out for each other. And we watch out for the young people."

A mile south of Badju's street, hundreds of university students gathered on the beach every afternoon. It was workout heaven; men lifted weights and men and women jogged back and forth in the sand.

When they stopped to cool down, several of the young men talked about AIDS and sex. Some said they had engaged in premarital sex; some acknowledged using condoms inconsistently.

"It's not very smart, I know," said Fadel Kane, 25, who is studying English. "I know it is dangerous not to use a condom, but sometimes in a long relationship, you just don't use one."

But others on the beach said their Muslim faith and their fitness habits kept them chaste.

"People are so free with sex in other countries, both in Africa and the West," said Daouda Diouf, 22. "Here we are not so free with sex. I think that has helped save us from AIDS."

He also voiced a belief that the government played a role. "People aren't afraid to talk about it," he said. "Except people with AIDS themselves."

Some fear the truth

Dark rashes, one of HIV's fingerprints, cover the arms and legs of Ndeye Debo Sour. She is 38 and a grandmother; she has been a prostitute for much of her adult life. For nine years she has lived with the virus.

"I lost my husband, I'm the mother of eight, I have no income, so this is what I do," she said, sitting in her one-room apartment, which was furnished with only a mattress on the floor. "My religion doesn't allow it, but what else can I do?"

When she sees other prostitutes, Sour encourages them to register with a health clinic and receive checkups. "I don't want the virus to be spread, and I want them to know how to behave and avoid getting it."

But many of the women say no. "They are afraid to know the truth, and they are afraid that their neighbors will find out" that they are infected, Sour said.

Anthonia Jacob and Kate Eno, the roommates who share a bed, signed up in the program, if only to keep working. Police frequently check to see if they have the identification card issued by health workers.

Jacob arrived in Dakar about two years ago. She fled her native Nigeria after several people in her village were killed, including her younger brother and sister, either by robbers or in cross-border skirmishes with troops from Cameroon.

Eno, who is also a Nigerian, arrived about a year ago. The women found each other through a Nigerian exile group in Dakar.

Both hate their lives. "I go into the night just so I can eat," Jacob said, sitting against the wall in her apartment. "Nowhere prostitutes go is safe. I've gotten beaten up. I've gotten raped. It's too horrible even to talk about."

Jacob has tried other work. She cleans floors in a tiny Internet cafe, but it pays little. She has posted a version of her life story on Internet message boards, has sent e-mail messages to those who respond, and has received rent money for a few months from a man in Chicago. She has written three songs, including one about returning to Nigeria and planting a garden to feed herself. It ends, in pidgin English, with, "Plenty good goin' come me, I no do prostitution again."

Outside her apartment, a child wailed. "Africa is noisy," she said, as she began caressing the cheek of a large plastic doll on her lap.

"This is Felix," she said, rubbing the doll's back; its large blue eyes stared into the distance. "It's the name of my dead brother." Jacob has an identical doll, which she had left at the health clinic, and which she had named Felicia, after her dead sister.

"Growing up, I never had a doll," Jacob said. "It helps me sometimes to hold them -- when I'm bothered. People are afraid of them because of their eyes. They think they are like voodoo, that I can kill someone with them."

Jacob laughed, and laid the doll down. She picked up a jagged piece of a mirror, looked at her braided hair, and walked into the next room. It was nearing time to go out and work.

The prostitutes in Dakar are believed to be the longest-studied such group in the world. Harvard and local AIDS researchers began documenting their lives in 1985. Since then the study has included more than 4,200 people. Among the 844 prostitutes who now come in for checkups, the average age is 38. The youngest is 22, the oldest 65. The prostitutes have been working an average of nine years, although one says she has been in the business for 33 years.

"But what's amazing about them is that 80 percent are HIV-negative," said Phyllis J. Kanki, a Harvard AIDS researcher who has conducted studies in Senegal for almost 20 years. In most of Africa, a 20 percent HIV rate among prostitutes is considered low. In Kenya, another long-studied group had rates approaching 95 percent, and in Uganda, 76 percent of one group of prostitutes were infected.

Meanwhile, the infection rate in Senegal has remained remarkably stable.

Kanki said she knew of no other place in Africa that offers prostitutes such comprehensive medical care, which includes everything from eye exams to prenatal care for those who become pregnant to antiretroviral drugs for those who contract HIV.

"Sometimes when I give talks about the prostitutes, people attack me because they feel that we are not doing enough to help the women get out of prostitution," Kanki said. "But I do think the program has helped most of them stay healthy, especially considering what they do for a living."

The head start

In Senegal, the fight against AIDS started before health authorities had a recorded a single case.

By the mid-1980s, scientists were confirming many cases in central and eastern Africa. Senegalese health officials alerted clinics around the country. In 1986, a migrant worker from northern Senegal was confirmed as the nation's first AIDS case.

Even before that, the scientific community was hard at work on the AIDS crisis and had achieved a breakthrough. In 1985, a team of Senegalese, Harvard, and French academics in Dakar discovered HIV-2, a virus related to HIV-1, which now has seven known subtypes.

Initially, HIV-2 was the prevalent strain in Senegal. It infects people at a lower rate and develops much more slowly than HIV-1 -- another key break for Senegal in the early days of the disease. Since the mid-1990s, however, HIV-1 has become the dominant strain in Senegal, heightening fears that the virus will again spread rapidly if prevention efforts ebb.

Leading the research in those early days were some of the giants in the field, including the Harvard AIDS Institute's Max Essex, Richard Marlink, and Kanki. But most influential in Senegal, then and now, was the country's chief scientist, Souleymane Mboup, and a growing cadre of associates.

Mboup, 52, head of the laboratory of bacteriology and virology at Universite Cheikh Anta Diop in Dakar, says the pride the country felt in discovering HIV-2 helped slow the course of the virus. People wanted to talk about Senegal's role; AIDS was not shunned as a topic.

"It meant you could talk about AIDS in a positive way here in Senegal!" he said, waving his arms in his office as if it happened just yesterday. "That made things easier than perhaps any other country. We were the scientists in front of the problem. And that gave us legitimacy."

Mboup, who is also a colonel in the army, said health officials adopted a militaristic approach. "We acted like soldiers would in fighting an enemy," he said. "The worst enemy we ever had was AIDS. It can kill more than war, and so we did everything we could to kill AIDS."

That meant building a lab. Using grants from Harvard University, the US government, the European Union, and Senegal, the lab is now equipped with high-tech gear that would outshine many AIDS laboratories in the United States.

Here, scientists insert gloved hands into biosafety cabinets, or hoods, to handle blood. They preserve cells inside liquid nitrogen tanks and run laser equipment that can assess a person's immune system. They are also equipped to obtain small samples of a person's DNA to learn about levels of the HIV virus in the blood.

"You will not find another lab like this in Africa, or most of the world," Kanki said. "It is a research institution and it is also a hospital diagnostics lab, but the most distinguishing thing about it are the Senegalese people running it and doing everything. In my experience with AIDS, you don't see that very often. You see different kinds of relationships, where you have a European or an American heading the lab. If you want to have sustained efforts like this, you have to get out of that formula. You'll never have the leadership."

On a recent afternoon, 21 workers in Mboup's lab gathered in his office and reviewed their work. The researchers became animated as they debated the challenges ahead.

Several talked about using new machines that have reduced the cost of measuring the health of a person's immune system. Tests measuring CD4 counts, which once cost $12, are now $1. Viral load tests are still $10 each, but lab workers are exploring ways to reduce that.

Senegal was also among the first African nations to begin, in 1998, treating AIDS patients with antiretroviral drugs, routine treatment in the developing world but comparatively rare outside it. Today, 1,400 Senegalese are receiving the costly drugs, 95 percent of them for free.

Lab tests here have not found any signs of resistance to the drugs -- another important finding by the Senegalese, as access to antiretroviral treatment is about to increase exponentially in sub-Saharan Africa, given growing foreign aid.

A fight on the streets

But a research lab, no matter how well-staffed and well-equipped, is no match for what happens in the streets of Senegal. The scientists know that in the fight against AIDS, so much depends on human behavior, specifically the behavior of prostitutes -- the highest risk group of all.

Outside Jacob and Eno's neighborhood of Gueule Tapee -- named after a lizard-like reptile -- large groups of men hang out on weekends until dawn. Late one night, the two prostitutes picked over a meal of grilled fish and buttered carrots, and considered the fragile nature of their health.

Jacob said she wasn't sure the clinic was telling her the truth about her HIV status. "How do I really know I'm negative?" she said loudly, her breath smelling of gin. "You know, if I have that virus, if I'm positive, I will not die alone. I will make sure I will share it with everybody."

She paused.

"I am just speaking my mind," she said. "Not everybody will tell you this, but some feel it. The best thing they could do to someone with HIV is put the person in the hospital or a jail."

"Stupid girl," Eno told her. "This sickness is something that if you ever had it, you'd be so ashamed. I would. I'd be scared."

Shyly, Eno said she had always felt at risk of getting the virus and now she felt trapped by not being able to find another way to live. "The only thing that would make me feel good is when I get married and when I have my children," she said. "Right now, I'm not happy, nothing makes me feel good, nothing."

A Muslim call to prayer sounded from a speaker in a nearby minaret. Dinner ended, and Jacob stood unsteadily. The young women flagged a cab, slipped inside, and vanished into the night.